Anales de Pediatría (English Edition) Anales de Pediatría (English Edition)
An Pediatr (Barc) 2017;87:155-63 - Vol. 87 Num.3 DOI: 10.1016/j.anpede.2016.07.007
Original Article
Early clinical trials in paediatric oncology in Spain: A nationwide perspective
Ensayos clínicos precoces en oncología pediátrica en España: una perspectiva nacional
Francisco Bautistaa,, , , Soledad Gallegob, Adela Cañetec, Jaume Morad, Cristina Díaz de Herediab, Ofelia Cruzd, José María Fernándezc, Susana Rivesd, Pablo Berlangac, Raquel Hladunb, Antonio Juan Ribellesc, Luis Maderoa, Manuel Ramíreza, Rafael Fernández Delgadoe, Antonio Pérez-Martínezf, Cristina Matag, Anna Llortb, Javier Martín Brotoh, María Elena Celag, Gema Ramírezh, Constantino Sábadob, Tomás Achai, Itziar Astigarragaj, Ana Sastref, Ascensión Muñozk, Mercedes Guibelaldel, Lucas Morenoa,m, on behalf of the Sociedad Española de Hematología and Oncología Pediátrica (SEHOP) and the New Drug Development Group in Pediatric Oncology
a Unidad de Investigación Clínica CNIO-HNJ, Servicio de Hematología, Oncología y Trasplante de Progenitores Hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
b Unidad de Oncología Pediátrica, Hospital Vall d??Hebron, Barcelona, Spain
c Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
d Unidad de Oncología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
e Unidad de Oncología Pediátrica, Hospital Clínico, Valencia, Spain
f Unidad de Oncología Pediátrica, Hospital La Paz, Madrid, Spain
g Unidad de Oncología Pediátrica, Hospital Gregorio Marañón, Madrid, Spain
h Unidad de Oncología Pediátrica, Hospital Virgen del Rocío, Sevilla, Spain
i Unidad de Oncología Pediátrica, Hospital Carlos Haya, Málaga, Spain
j Unidad de Oncología Pediátrica, Hospital Universitario Cruces, Barakaldo, IIS BioCruces, Universidad del País Vasco (UPV/EHU), Spain
k Unidad de Oncología Pediátrica, Hospital Miguel Servet, Zaragoza, Spain
l Unidad de Oncología Pediátrica, Hospital Universitario Son Espases, Palma de Mallorca, Spain
m Instituto de Investigación La Princesa, Madrid, Spain
Received 12 July 2016, Accepted 24 July 2016
Abstract
Introduction

Cancer is the leading cause of death between the first year of life and adolescence, and some types of diseases are still a major challenge in terms of cure. There is, therefore, a major need for new drugs. Recent findings in cancer biology open the door to the development of targeted therapies against individual molecular changes, as well as immunotherapy. Promising results in adult anti-cancer drug development have not yet been translated into paediatric clinical practice. A report is presented on the activity in early paediatric oncology trials (phase I–II) in Spain.

Material and methods

All members of the Spanish Society of Paediatric Haematology Oncology (SEHOP) were contacted in order to identify early clinical trials in paediatric cancer opened between 2005 and 2015.

Results

A total of 30 trials had been opened in this period: 21 (70%) in solid tumours, and 9 (30%) in malignant haemopathies. A total of 212 patients have been enrolled. The majority was industry sponsored (53%). Since 2010, four centres have joined the international consortium of Innovative Therapies for Children with Cancer (ITCC), which has as its aim to develop novel therapies for paediatric tumours. A significant number of new studies have opened since 2010, improving the treatment opportunities for our children. Results of recently closed trials show the contribution of Spanish investigators, the introduction of molecularly targeted agents, and their benefits.

Conclusions

The activity in clinical trials has increased in the years analysed. The SEHOP is committed to develop and participate in collaborative academic trials, in order to help in the advancement and optimisation of existing therapies in paediatric cancer.

Resumen
Introducción

El cáncer es la primera causa de muerte por enfermedad entre el primer año de vida y la adolescencia. Algunos tipos de enfermedad siguen constituyendo un reto en términos de curación. Existe por tanto una necesidad imperiosa de nuevos fármacos. Algunos descubrimientos recientes en la biología del cáncer abren la puerta al desarrollo de terapias dirigidas contra alteraciones moleculares concretas e inmunoterapia. Esto se ha traducido en resultados prometedores sobre todo en oncología de adultos, y en menor medida todavía en niños. Presentamos la actividad en ensayos clínicos precoces (fase i-ii) en oncología pediátrica en España.

Material y métodos

A través de la Sociedad Española de Oncología y Hematología Pediátrica (SEHOP) contactamos a sus miembros para identificar los ensayos fase i-ii en cáncer pediátrico abiertos entre 2005 y 2015.

Resultados

En este periodo se abrieron 30 ensayos: 21 (70%) en tumores sólidos y 9 (30%) en hemopatías malignas y se incluyó a 212 pacientes. La mayoría están promovidos por la industria farmacéutica (53%). Desde 2010, 4 centros se han integrado en el consorcio internacional ITCC cuyo objetivo es desarrollar nuevas terapias en cáncer infantil. Esto ha permitido ampliar el abanico de posibilidades terapéuticas. Los resultados de ensayos clínicos terminados muestran la contribución de los investigadores españoles, la introducción de terapias dirigidas y sus beneficios.

Conclusiones

La actividad en ensayos clínicos precoces ha aumentado en estos años. La SEHOP está comprometida a desarrollar y participar en ensayos clínicos académicos colaborativos, que favorezcan el avance en las terapias frente al cáncer infantil.

Keywords
Paediatric haematology and oncology, Early phase clinical trials, Drug development, Personalised medicine
Palabras clave
Oncología y hematología pediátrica, Ensayos clínicos precoces, Desarrollo de nuevos fármacos, Medicina personalizada
Introduction

In Spain, a new case of cancer is diagnosed in 1 out of 6,500 children aged less than 15 years every year. This amounts to 1,100 new cases in children aged 0 to 14 years, while there are 450 in adolescents aged 15–19 years.1

There have been enormous medical and therapeutic advances in paediatric cancer. In Europe, the mortality associated with childhood cancer decreased by 60% between the 1950s and the 1990s.2 These figures have continued to improve since, although there has been a plateau in some diseases.1 In Europe, the overall 5-year survival for all types of cancer diagnosed between 2000 and 2007 was 77.9%.3 This success is due in large part to the development of multicentric clinical trials conducted by collaborative research groups.4

However, cancer continues to be the leading cause of death by disease from the first year of life and through adolescence1: in 2014, cancer caused 29% of deaths in children aged 1–14 years, and 20% of deaths in adolescents aged 15–19 years.5

More specifically, the prognosis of certain diseases continues to be bleak, for instance in metastatic medulloblastoma, sarcoma or neuroblastoma, high-grade glioma or in patients with other types of cancer that recurs or is refractory to first-line treatment.

Thus, there is a pressing need for new drugs.

These novel anticancer drugs are needed to improve survival and reduce the sequelae that result from multimodal treatment combining surgery, radiotherapy, chemotherapy and haematopoietic stem cell transplantation. Recently, the identification of particular molecular changes in specific tumours has led to the development of targeted therapies against them, which has come to be known as “precision medicine.”6 This has opened the door to strategies adapted to the presence of molecular changes or immunotherapy at the time of diagnosis or relapse, which are exclusive to oncology patients.

There is evidence of the usefulness of new targeted therapies in some paediatric solid tumours: ALK inhibitors for anaplastic large-cell lymphoma,7,8 Sonic-hedgehog signalling pathway inhibitors for medulloblastoma9 or BRAF inhibitors for high-grade glioma in patients with BRAF-V600E mutations.10,11

In leukaemia, the best 2 examples correspond to chronic myelogenous leukaemia and acute lymphoblastic leukaemia, in which the discovery of the Philadelphia chromosome (t(9;22)(q34;q11)) allowed the identification of the BCR-ABL fusion protein, which plays an essential role in their pathogenesis. This finding has allowed the development of drugs such as imatinib, dasatinib or nilotinib that can kill leukaemia cells through the inhibition of ABL kinase activity, improving the prognosis of these patients.12,13

Thus, continued investment in research and development of novel anticancer agents for paediatric cancer is of vital importance.

Motivated by the dearth of paediatric data for already authorised medicines, new legislation was introduced in Europe in 2007 regarding the regulation of medicines in paediatrics that refers to the “paediatric investigation plan” that pharmaceutical companies need to submit to the European Medicines Agency at the time of applying for authorisation of a new drug.14 Thus, whenever a pharmaceutical company gets a new drug authorised (usually for the adult population), it must be accompanied by a plan for paediatric development (as long as the drug is potentially useful in children). When paediatric investigation plans are completed satisfactorily, the medicine is eligible for a 6-month supplementary protection certificate, or in case of a so-called orphan medicinal product, for an extension of 2 years to the 10 years of market exclusivity for the already authorised indication.

The aims of this measure are15:

  • -

    To increase availability of new medicines authorised for use in children through generation of accurate safety and efficacy data and high-quality ethical paediatric clinical research

  • -

    To produce better information on existing paediatric medicines.

Despite the introduction of these initiatives in Europe in the past 15 years, the development of novel drugs for the treatment of paediatric cancer is still insufficient: 14 out of the 28 anticancer agents approved for adults have been waived for paediatric development, while 26 of them were relevant to childhood cancers.16 Thus, it is necessary for representatives of academic institutions, regulatory bodies, the pharmaceutical industry, parent organisations, patient rights advocacy groups and other charities to continue working and collaborating closely to facilitate children access to these new drugs.16

Generally speaking, the use of certain drugs in patients with refractory or relapsed cancer is not based on a solid foundation of scientific evidence, and most are not indicated for the paediatric age group. The off-label use of drugs that are only authorised in adults carries significant risks and does not help improve the scientific evidence on their use.17

Traditionally, the development of a new drug involves different phases (I through III) to evaluate its toxicity and safety (I), efficacy (II) and improvements in survival (III) in specific populations.18 Phase IV trials are postmarketing studies that seek to identify toxicities that were not observed previously and assess long-term efficacy. When it comes to oncology, the subset of patients that participate in early-phase trials (I and II) mostly consists of those who have relapsed after at least one course of treatment, or with refractory cancer. This is a long and costly process—usually more than 10 years from target identification in a laboratory to marketing with costs of up to 2000 million dollars per product.19 Fewer than 5% of medicines evaluated in phase I clinical trials gain market authorisation,20 and only 1 out of 10000 compounds ever reach the market.21

Along these lines, the Innovative Therapies For Children With Cancer consortium (ITCC; http://www.itcc-consortium.org) is an international organisation whose principal aim is to evaluate novel therapies for the treatment of cancer in children and adolescents. The ITCC provides the necessary accreditation to develop and implement clinical trials in childhood cancer, facilitates contact with academic or pharmaceutical industry sponsors, and opens new clinical research centres22 with the purpose of expediting access to these medicines for children.

The aim of this study is to describe the activity in early-phase clinical trials in paediatric cancer in Spain in the past 10 years, to evaluate the hurdles that we are facing, their potential solutions, and future challenges. This study will provide a reference for this field for future comparison, following the example of the BEST project of Farma Industry, an association that seeks to promote excellence in clinical research of medicines in Spain and to assess performance, efficacy and quality in the field (www.farmaIndustry.es).

Patients and methods

The Sociedad Española de Hematología y Oncología Pediátrica (Spanish Society of Paediatric Haematology and Oncology [SEHOP]; www.sehop.org) represents all paediatric oncology units in Spain. We contacted all the SEHOP members to identify phase I and II trials for solid tumours and blood cancers initiated between 2005 and 2015. We chose this period because in Spain, early-phase trials in the paediatric population started to be conducted in 2005.

For each of the trials, we collected data regarding the type of trial (phase I or II), sponsor (academia or pharmaceutical industry), number of participating centres, enrolment period, type(s) of tumour(s) under study, drug under investigation, mechanism of action and number of patients enrolled in the trial. We updated these data on December 1, 2015. We checked whether trials were still recruiting patients in June 15, 2016.

When further information was needed, we resorted to the clinical trials registry of the United States National Institutes of Health (www.clinicaltrials.gov), the European Union Clinical Trials Register (www.clinicaltrialsregister.eu) and the Spanish Register of Clinical Trials of the Agencia Española del Medicamento y Productos Sanitarios (Spanish Agency of Medicines and Medical Devices [AEMPS]; https://reec.aemps.es).

ResultsCentres with units devoted to early-phase clinical trials: The role of the ITCC consortium

Since 2010, 4 Spanish hospitals have joined the ITCC consortium: the Hospital Universitari La Fe in Valencia; the Hospital Universitari Vall d’Hebron in Barcelona, the Hospital Niño Jesús in Madrid and the Hospital Sant Joan de Déu in Barcelona. Other centres that are members of the SEHOP have also partaken in some of the studies described here, most of them phase II trials: La Paz, Gregorio Marañón and Doce de Octubre hospitals (Madrid), Hospital Santa Creu i Sant Pau (Barcelona), Hospital Virgen del Rocío (Seville), Hospital Virgen de la Arrixaca (Murcia), Hospital de Cruces (Bilbao), Hospital Son Espases (Palma de Mallorca), Hospital Clínico (Valencia), Hospital Universitario de Canarias (Tenerife), Hospital Miguel Servet (Zaragoza), Hospital Central de Asturias (Oviedo), Hospital Regional Universitario (Malaga) and Hospital General Universitario (Alicante).

Paediatric oncology clinical trial portfolio

Tables 1 and 2 list the early-phase clinical trials in patients with solid tumours and blood cancer, respectively, initiated between 2005 and 2015 in Spain.

Table 1.

Ongoing paediatric phase I/II clinical trials for solid tumours in Spanish centres between 2005 and 2015.

Drug under study/name of clinical trial  Mechanism of action  Trial phase  Disease  Sponsor  Number of participating centres  Reference 
CLDK378X2103  ALK-TKI  Solid tumours with ALK mutations  Industry  NCT01742286 
Afatinib  Multi-TKI  Brain tumours and rhabdomyosarcomas  Industry  NCT02372006 
BRIM-P: vemurafenib  BRAF-TKI  Melanoma  Industry  NCT01519323 
Lenvatinib  VEGFR-TKI  I/II  Solid tumours  Industry  EudraCT: 2013-005534-38 
Dabrafenib  BRAF-TKI  I/II  Solid tumours with BRAF-V600E mutation  Industry  NCT01677741 
Abraxane
(nab-placitaxel) 
Cytotoxic agent  I/II  Solid tumours  Industry  NCT01962103 
CELYVIR  Oncolytic virus  I/II  Solid tumours  Academia  1  NCT01844661 
Haplo TPH+IL-15 NK  Haplo TPH+IL-15 NK  I/II  Solid tumours  Academia  1  NCT01337544 
LTI ch14.18/CHO-IL2  Immunotherapy  I/II  Neuroblastoma  Academia  NCT01701479 
Dinutuximab-IL2  Immunotherapy  II  Neuroblastoma  Academia  NCT02169609 
BEACON  Cytotoxic agent±antiVEGF mAb  II  Neuroblastoma  Academia  NCT02308527 
Irinotecan/cisplatin  Cytotoxic agent  II  Brain tumours  Academia  1  NCT01574092 
HERBY  Cytotoxic agent+radiotherapy+antiVEGF mAb  II  High-grade gliomas  Industry  10  EudraCT:
2010-022189-28 
TEMIRI (temozolomide+irinotecan)  Cytotoxic agent  II  Medulloblastomas and high-grade gliomas  Academia  3  EudraCT:
2006-005476-40 
TOTEM (topotecan+temozolomide)  Cytotoxic agents  II  Solid tumours  Academia  3  NCT00918320 
Ipilimumab  Anti-CTLA-4 mAb  II  Melanoma  Industry  NCT01696045 
Sunitinib  Multi-TKI  II  GIST  Industry  NCT01396148 
GEIS-21
(gemcitabine+docetaxel) 
Cytotoxic agents  II  Ewing sarcoma  Academia  8  NCT01696669 
rEECur  Cytotoxic agents  II  Ewing sarcoma  Academia  17  EudraCT:
2014-000259-99 
GEIS 29 (gemcitabine+rapamycin)  Cytotoxic agent+mTOR inhibitor mTOR  II  Osteosarcoma  Academia  15  NCT02429973 
BERNIE  Cytotoxic agents+antiVEGF mAb  II  RMS and non-RMS soft tissue sarcomas  Industry  4  NCT00643565 

Clinical trials that are no longer recruiting patients as of June 15, 2016 are presented in boldface.

CTLA-4, cytotoxic T-lymphocyte antigen 4; GIST, gastrointestinal stromal tumour; HSCT, haematopoietic stem cell transplantation; IL, interleukin; mAb, monoclonal antibody; RMS, rhabdomyosarcoma; TKI, tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor; VEGFR, vascular endothelial growth factor receptor.

Source: www.clinicaltrials.gov/www.clinicaltrialsregister.eu.

Table 2.

Ongoing paediatric phase I/II clinical trials for blood cancers in Spanish centres between 2005 and 2015.

Drug under study/name of clinical trial  Mechanism of action  Trial phase  Disease  Sponsor  Number of participating centres  Reference 
LANK-2  NK cell therapy+cytotoxic agents  Acute lymphoblastic and myeloid leukaemia  Academia  NCT02074657 
HNJ-NKAES-2012  NK cell therapy+cytotoxic agents  T-cell acute lymphoblastic leukaemia and T-cell lymphoblastic lymphoma  Academia  NCT01944982 
Dacogen  Hypomethylating agent+ cytotoxic agent  I/II  Acute myeloid leukaemia  Industry  NCT01853228 
Brentuximab  mAb anti-CD30  I/II  Anaplastic large-cell lymphoma and Hodgkin lymphoma  Industry  NCT01492088 
Carfilzomib  Proteasome inhibitor±cytotoxic agent  I/II  Acute lymphoblastic leukaemia  Industry  NCT02303821 
Nilotinib  TKI  II  Ph+ chronic myelogenous leukaemia  Industry  3  NCT01844765 
Dasatinib  TKI  II  Ph+ chronic myelogenous leukaemia  Industry  6  NCT00777036 
Moxetumomab  Anti-CD22 mAb  II  Acute lymphoblastic leukaemia and lymphoblastic lymphoma  Industry  2  NCT02227108 
Inter-B-NHL-RITUX 2010  Rituximab (mAb anti-CD20)±cytotoxic agents  II  Primary mediastinal B-cell lymphoma  Academia  30  NCT01516580 

Clinical trials that are no longer recruiting patients as of June 15, 2016 are presented in boldface.

mAb, monoclonal antibody; NK, natural killer; TKI, tyrosine kinase inhibitor.

Source: www.clinicaltrials.gov/www.clinicaltrialsregister.eu

A total of 30 trials have been launched: 21 (70%) in patients with solid tumours and 9 (30%) in patients with blood cancers.

Of the trials for solid tumours, 3 (14%) are separate phase I trials, 6 (29%) are parallel phase I/II trials, and 12 (57%) are separate phase II trials. Six (28%) are assessing tyrosine kinase inhibitors (TKIs), 6 (28%) cytotoxic agents, 3 (14%) a combination of cytotoxic agents with a monoclonal antibody (mAb), 2 (9%) a combination of 2 immunotherapy drugs for neuroblastoma, 1 (5%) a mAb for melanoma, 1 (5%) the combination of a TKI with a cytotoxic agent for osteosarcoma, 1 (5%) an oncolytic virus (Celyvir23,24) and 1 (5%) a combination of interleukin-15-stimulated natural killer cells and haploidentical hematopoietic stem cell transplantation. Two trials (10%) focused on tumours with specific molecular changes, 14 (66%) on specific types of tumours and 5 (24%) were for solid tumours of any type. Half of the trials were sponsored by pharmaceutical companies and the other half by academic institutions; 15 (72%) focused exclusively on the paediatric population (age <18 years), 4 (19%) included young adults up to age 21 years and 2 (9%) included paediatric as well as adult patients.

Of the blood cancer trials, 2 (22.2%) were phase I trials, 3 (33.3%) were phase I/II trials, and 4 (44.5%) phase II trials; 2 (22.2%) studied a TKI, 2 (22.2%) a mAb, 2 (22.2%) cell therapy with and without chemotherapy, 1 (11.1%) a combination of a mAb with cytotoxic agents, 1 (11.1%) a hypomethylating agent and 1 (11.1%) a proteasome inhibitor. Two trials (22.2%) focused on diseases with specific molecular changes and 7 (77.8%) on specific blood cancers. Most are sponsored by the pharmaceutical industry (n=6.66%). They are all exclusively focused on the paediatric population under 18 years.

Table 3 shows the considerable increase in the options available for the groups of diseases for which clinical trials have been available in the past 5 years in Spain.

Table 3.

Clinical trials conducted between 2010 and 2015 by specific disease groups.

Clinical trials2010  2015 
Brain tumoursHigh-grade glioma     
Low-grade glioma     
Medulloblastoma     
Other brain tumours     
Leukaemia, lymphomaALL     
AML     
CML     
Lymphoma     
Solid tumoursOsteosarcoma     
Ewing sarcoma     
Rhabdomyosarcoma     
Other sarcomas     
Neuroblastoma     
Melanoma     
Other solid tumours     

ALL, acute lymphoblastic leukaemia; AML, acute myeloid leukaemia; CML, chronic myelogenous leukaemia.

Enrolment in paediatric cancer clinical trials

A total of 212 patients were enrolled during this period: 179 (84%) in solid tumour clinical trials and 33 (16%) in blood cancer clinical trials.

Completed clinical trials

The findings of completed trials and of ongoing trials whose intermediate results have been made available demonstrate the positive contribution of Spanish researchers, the introduction of targeted molecular therapies in the paediatric population and the benefits that patients may derive from these new drugs (Table 4).8,10,23,25–31

Table 4.

Summary of some of the completed trials.

Clinical trial [Ref]  Results 
Ceritinib
(LDK 378)8 
22 patients aged less than 18 years with relapsing/refractory tumours with ALK mutations/changes. Patients were treated with increasing doses of ceritinib
RP2D: 510mg/m2. Pharmacokynetics comparable to those in adults
2 DLTs at doses of 560mg/m2/day. Frequent AEs: diarrhoea, vomiting, nausea, elevated ALT
6 objective responses: 2 of 2 patients with LCAL and 4 of 7 patients with MT/IMT 
Dabrafenib10  27 patients aged less than 18 years with relapsing/refractory tumours with BRAF mutations/changes. Patients were treated with increasing doses of dabrafenib
RP2D: 4.5mg/kg/day for patients >12 years and 5.25mg/kg/day for patients <12 years
1 TLD at 4.5mg/kg/day. Frequent AEs: hypotension, skin rash, DIC, fever and arthralgia
23 objective responses: 6 of 8 patients with high-grade glioma, 14 of 15 with low-grade glioma, 2 LCH, 1 other type of solid tumour 
Abraxane (nab-paclitaxel)25  64 patients aged less than 18 years with relapsing/refractory solid tumours except brain tumours
Patients were treated with increasing doses of nab-paclitaxel
RP2D: 240mg/m2
2 TLD at doses of 120mg/m2 and 270mg/m2 (dizziness and neutropaenia, respectively)
5 partial responses 
Celyvir23  14 patients aged less than 18 years with refractory or relapsed neuroblastoma
Weekly infusion of autologous pluripotent mesenchymal stem cells carrying an oncolytic virus (range, 4–70)
Total cells (min, 70×106, max 2.640×106) and viral particles (min, 1.80×1012; max, 5.280×1013)
No serious adverse events
4 objective responses: 1 stable disease, 2 partial remissions and 1 full remission 
Haplo+IL-15 NK cell31  6 patients aged less than 18 years with refractory sarcoma and relapsed adrenal gland carcinoma
DLI of haploidentical NK cells obtained by immunomagnetic separation in GMP conditions and stimulated with IL-15 overnight.
Total infused cells 11×106/kg (3–27×106/kg)
No serious adverse events associated with NK cell infusion
4 objective responses: 1 stable disease, 2 partial remissions and 1 highly favourable partial remission 
LTI ch14.18/CHO-IL226  97 patients aged less than 21 years with high-risk neuroblastoma
Pharmacokinetics of ch14.18/CHO in cycle 1: Cmax=12.2±0.4μg/mL, t½=8.4±1.1 d, AUC=145.3±5.8μgd/mL
1-year and 4-year PFS: 54.4%±06.9% and 32.3%±06.9% versus 19%±02% and 8%±03% of historical controls
1-year and 4-year OS: 94.2%±03.2% and 60.9%±09.0% versus 56%±03% and 14%±04% of historical controls 
GEIS-2127  43 patients with Ewing sarcoma aged less than 40 years in first-line treatment
22 SR patients and 21 HR patients
Chemotherapy with mP6, surgery and radiation in SR patients and window evaluation of gemcitabine/docetaxel in HR patients
4-year EFS and OS in SR patients were 67% and 74%, respectively
4-year EFS and OS in HR patients were 67% and 42%, respectively
EFS and OS were significantly higher in the under-18 years group 
TEMIRI28  66 patients aged less than 18 years with relapsing/refractory medulloblastoma
Patients were treated with temozolomide on days 1–5 and irinotecan on days 1–5 and 8–12 every 21 days
The most frequent toxicities were haematologic and gastrointestinal (diarrhoea)
The objective response rate was 33%, and 68% showed clinical improvement 
TOTEM29  38 patients aged less than 18 years with relapsing/refractory neuroblastoma
L patients were treated with temozolomide on days 1–5 and topotecan on days 1–5 and 8–12 every 28 days
The most frequent toxicity was haematologic
1-year PFS and OS were 42% and 58%, respectively 
BERNIE30  154 patients aged less than 18 years with metastatic rhabdomyosarcoma
80 were randomly allocated to the chemotherapy-only arm, and 74 to the chemotherapy+bevacizumab arm
The toxicity profile was similar in both groups
EFS was similar in both groups (12.5% vs 18.9%, P=.71)
OS was similar in both groups (42.2% vs 32.3%, P=.32) 

AE, adverse event; AUC, area under the curve; DIC, disseminated intravascular coagulation; DLI, donor lymphocyte infusion; DLT, dose-limiting toxicity; EFS, event-free survival; GMP, good manufacturing practice; HR, high risk; IMT, inflammatory myofibroblastic tumour; RP2D, recommended phase II dose; LCH, Langerhans cell histiocytosis; IL, interleukin; LCAL, large-cell anaplastic lymphoma; MT, myofibroblastic tumour; NK, natural killer; OS, overall survival; PFS, progression-free survival; SR, standard risk.

Discussion

This article describes the activity in the development of new treatments for paediatric cancer in Spain.

Children with cancers that are high-risk or carry a poor prognosis continue to have difficulty accessing new drugs. The number of trials opening in Spain has increased in the past 5 years, probably as a result of hospitals joining the ITCC, changes in legislation applying to paediatrics and institutional efforts to establish units devoted to these trials staffed by physicians, research nurses, project managers and data managers.

Between 2010 and 2014, 4 centres have joined the ITCC, a consortium established in 2003 that comprises 9 European basic research laboratories and 47 paediatric oncology centres with the necessary resources to carry out phase I and II clinical trials in paediatric oncology. One of the aims of the consortium is to develop novel therapies for paediatric malignancies in collaboration with pharmaceutical companies, regulatory bodies and patient and parent associations.22 Since 2007 the number of drugs in early phase trials being run by the ITCC has grown from one in 2007 to 12 in 2013, with half of these trials being conducted to comply with the regulatory requirements of a paediatric investigation plan; this has significantly improved access of European children to novel therapies.15 For Spain, being actively involved in the ITCC allows us to participate in international collaborative trials, which facilitates access to promising therapies to our patients.

Most of the early-phase clinical trials in paediatric oncology and haematology that have opened in Spain have been sponsored by the pharmaceutical industry (n=16; 53%). Only one third of the total focus on blood cancers. This is possibly due to the fact that the overall cure rate with first-line treatment is high for leukaemias and lymphomas, and that a significant percentage of patients that relapse achieve full remission for the second time and eventually a cure with conventional chemotherapy or haematopoietic stem cell transplantation. Thus, the target paediatric population for new drugs for blood cancers is smaller. Recruitment is further complicated by the stringent inclusion and exclusion criteria, the challenges involved in transferring patients from their original hospitals to the centres where these new therapies are available, and the natural history of the disease, which sometimes does not allow delays in treatment initiation. These factors also apply to solid tumour patients, and in specific nervous system diseases or sarcomas, there are even fewer clinical trials.

For all the above reasons, paediatric cancer as a whole constitutes a “small” market with few incentives for the pharmaceutical industry.32

We believe that these groups of “orphan” patients should benefit from academic clinical trials. From our paediatric haematology and oncology society,33 and in collaboration with other scientific societies, such as the Grupo Español de Investigación en Sarcomas (Spanish Sarcoma Research Group [GEIS]), we aim to develop and participate in collaborative academic clinical trials to promote therapeutic advances and the optimisation of existing therapies for rare diseases like childhood cancer, which are not usually the target of pharmaceutical companies. Our duty as researchers is to improve on study design to add adaptability and flexibility, and to develop trials on the basis of solid scientific evidence so that they target populations that are more likely to show a favourable response.34 In this regard, the Sociedad Española de Oncología Médica (Spanish Society of Medical Oncology) took an important initiative in addressing a manifesto to policymakers requesting support for independent academic clinical research.35

An added difficulty is the lack of funding for clinical development in academic settings. This poses barriers to participation in international academic clinical trials, as the costs of opening the trial at the local and national levels must be assumed nearly in full by participating countries. Few not-for-profit organisations fund paediatric cancer research programmes or have specific agendas to support clinical trials. The recent Royal Decree 1090/2015 regulating drug clinical benefits non-commercial clinical research studies through exemption of fees or reduced fees and by simplifying the costly and complex bureaucracy involved in opening such trials. Lack of funding does not only ail this side of the Atlantic. In the United States, 60% of the funding for biomedical research comes from the biopharmaceutical industry,36 followed by the National Institutes of Health, which contributes another 25%. However, funding from the pharmaceutical industry is nearly nonexistent in paediatric cancer, so that research in the field depends on the National Institutes of Health, private institutions and charities.32

On the bright side, the favourable outcomes observed in samples selected based on molecular findings and treated with targeted therapies such as ALK or BRAF inhibitors8,10,11 or with the use of anti-GD2 mAb in high-risk neuroblastoma26 are encouraging, so we must remain optimistic. Such evidence ought to stimulate investment in basic and clinical research and help patients be referred more easily to centres that can offer new therapies that may be beneficial.

The experience of 2 or the largest early-phase clinical trial units in paediatric oncology in Europe, the Royal Marsden (London, United Kingdom)37 and Gustave Roussy (Villejuif, France)38 proves that implementing these therapies in the context of everyday paediatric oncology practice is possible and safe for patients, while allowing a significant percentage of paediatric cancer patients to benefit from these treatments.

Clinical trials are a necessary and indispensable means to evaluate new treatments that can provide robust and solid data on their safety and efficacy, which is as beneficial to the scientific community as it is to patients. The evaluation of new anticancer drugs in children and adolescents must comply with current legislation, avoiding off-label use17,39 and in the context of clinical trials approved by ethics committees and conducted in adherence to good clinical practice principles.

Conflict of interests

The authors have no conflict of interests to declare.

Acknowledgments

We thank all children and parents that have participated in these clinical trials, as well as the clinical staff, research nurses and project and data managers of the various institutions.

We thank our colleagues from the Sociedad Española de Hematología y Oncología Pediátrica (SEHOP) for their enthusiasm and support.

We also acknowledge our colleagues from the Grupo Español de Investigación en Sarcomas (Spanish Sarcoma Research Group [GEIS]), whose collaboration with the SEHOP group gave our patients access to new clinical trials.

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Please cite this article as: Bautista F, Gallego S, Cañete A, Mora J, Díaz de Heredia C, Cruz O, et al. Ensayos clínicos precoces en oncología pediátrica en España: una perspectiva nacional. An Pediatr (Barc). 2017;87:155–163.

Corresponding author. (Francisco Bautista fjbautisir@gmail.com)
Copyright © 2016. Asociación Española de Pediatría
An Pediatr (Barc) 2017;87:155-63 - Vol. 87 Num.3 DOI: 10.1016/j.anpede.2016.07.007
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